Nurse practitioner

The advanced practice nursing role began to take shape in the mid-20th century in the United States. Nurse anesthetists and nurse midwives were established in the 1940s, followed by psychiatric nursing in 1954. The present day concept of advanced practice nursing as a primary care provider was created in the mid-1960s, spurred on by a national shortage of physicians.[7] The first formal graduate certificate program for NPs was created by Henry Silver, a physician, and Loretta Ford, a nurse, in 1965.[7] In 1971, The U.S. Secretary of Health, Education and Welfare, Elliot Richardson, made a formal recommendation in expanding the scope of nursing practice to be able to serve as primary care providers.[8] During the mid 1970s to early 1980s, the completion of a master's degree became required in order to become a certified NP. In 2012, discussions have risen between accreditation agencies, national certifying bodies, and state boards of nursing about the possibility of making the Doctorate of Nursing Practice (DNP) as the new minimum standard of education for NP certification and licensure by 2015.[9]

In Canada, advanced practice nursing first appeared in the 1990s in Ontario.[10] These nurses practiced in neonatal intensive care units within tertiary care hospitals in collaboration with pediatricians and neonatologists.[10] Although the role of these nurses initially resembled a blended version of clinical nurse specialists and NPs, today the distinction has been more formally established.[10]

The amount and quality of education required to be an NP has been the subject of controversy in the United States. Opponents of independent practice have argued that NP education can consist of online coursework with few hours of actual patient contact.[11] To become an NP requires between 1.5 to 3 years of post-baccalaureate training, in addition to prior training and experience as an RN, though there are alternate routes to training. In comparison to physicians who are required to complete a minimum of 7 years of post-baccalaureate training. A new nurse practitioner may have between 500 and 1,000 hours of clinical training, compared with a family physician, who would have more than 15,000 hours of clinical training by the time of certification.[1] The quality of education and of applicants for NP schools has been cited as a reason to not allow NPs to practice medicine autonomously. Some graduate nursing schools have 100% acceptance rates.[12]

A review of studies comparing outcomes of care by NPs and by physicians in primary care, urgent care, and anesthesia conducted by the Department of Veteran Affairs found that outcomes in the assessed studies were generally comparable, although the VA noted that the strength of evidence of the assessed studies was often low.[13]

In primary care settings, utilization of NPs under physician supervision may improve access to care. [14]. This issue can also be addressed by training more physicians.

In the U.S., because the profession is state-regulated, the scope of practice varies by state. Some states allow NPs to have full practice authority. However, in other states, a written collaborative or supervisory agreement with a physician is legally required for practice.[15] Autonomous practice was introduced in the 1980s, mostly in states facing a physician shortage or that struggled to find enough healthcare providers to work in rural areas.[16] The extent of this collaborative agreement, and the role, duties, responsibilities, nursing treatments, and pharmacologic recommendations again varies widely between states.[17][18][19]

NPs can legally examine patients, diagnose illness, prescribe some medications, and provide treatments. In 2017, twenty-two states gave full practice authority to NPs and do not require the supervision of a physician. Thirty-eight states require NPs to have a written agreement with a physician in order to provide care. Twelve of those states require NPs to be supervised or delegated by a physician, this physician may not be on site.[20]

In Canada, an NP is a registered nurse (RN) with a graduate degree in nursing. Canada recognizes them in primary care and acute care practice. NPs diagnose illnesses and medical conditions, prescribe Schedule 1 medications, order and interpret diagnostic tests, and perform procedures, within their scope of practice, and may build their own panel of patients at the same level as physicians[21]. Primary care NPs work in places like primary care and community healthcare centers, as well as long term care institutions. The main focus of primary care NPs includes health promotion, preventative care, diagnosis and treatment of acute and chronic diseases and conditions. Acute care NPs serve a specific population of patients. They generally work in in-patient facilities that include neonatology, nephrology, and cardiology units.[22] There are currently three specialties for Nurse Practitioners in Canada, Family Practice, Pediatrics, and Adult Care. NPs who specialize in Family Practice work at the same level and offer the same services as Family Physicians with the exclusion of Quebec, where only Physicians are allowed to formulate a medical diagnosis[23].

In the United Kingdom nurse practitioners carry out care at an advanced practice level. They often perform roles similar to those of doctors. They commonly work in primary care (e.g. GP surgeries) or A&E departments, although they are increasingly being seen in other areas of practice.

The path to becoming an NP in the U.S. begins by earning an undergraduate degree in nursing and requires licensure and experience as an RN. One must then complete graduate studies in nursing. Overall, to become an NP requires 1.5 to 3 years of post-baccalaureate training, compared to physicians who are required to complete a minimum of 7 years of post-baccalaureate training. A new NP has between 500 and 1,000 hours of clinical training compared with a family physician who would have more than 15,000 hours of clinical training by the time of certification.[1] The quality of education and applicants for NP schools has been cited as a reason to not allow NPs to practice medicine independently. Many schools accept all applications regardless of quality, coursework can be entirely online, and clinical experience can be limited to shadowing with no hands-on experience.[24][12]

In Australia, RNs who have the equivalent of three years of full-time experience (5000 hours) and have completed a program of study approved by the Nursing and Midwifery Board of Australia (a postgraduate nursing master's degree including advanced health assessment, pharmacology for prescribing, therapeutics and diagnostics and research), or a program that is substantially equivalent to an approved program of study, may apply to the Nursing and Midwifery Board of Australia for endorsement as a Nurse Practitioner.[25] The Australian professional organisation is the Australian College of Nurse Practitioners (ACNP).[26]

In Canada, the educational standard is a graduate degree in nursing. The Canadian Nursing Association (CNA) notes that advanced practice nurses must have a combination of a graduate level education and the clinical experience that prepare them to practice at an advanced level. Their education alone does not give them the ability to practice at an advanced level. Two national frameworks have been developed in order to provide further guidance for the development of educational courses and requirements, research concepts, and government position statements regarding advanced practice nursing: the CNA's Advanced Nursing Practice: A National Framework and the Canadian Nurse Practitioner Core Competency Framework. All educational programs for NPs must achieve formal approval by provincial and territorial regulating nurse agencies due to the fact that the NP is considered a legislated role in Canada. As such, it is common to see differences among approved educational programs between territories and provinces. Specifically, inconsistencies can be found in core graduate courses, clinical experiences, and length of programs. Canada does not have a national curriculum or consistent standards regarding advanced practice nurses. All advanced practice nurses must meet individual requirements set by their provincial or territorial regulatory nursing body.

As of November 2013, NPs were recognized legally in Israel.[27]